Vanderbilt ADHD Assessment (Parent)

NICHQ Vanderbilt Assessment Scale — PARENT Informant

Information

Today's Date This field is required

Child's Name This field is required

Child's Date of Birth This field is required

Parent's Name This field is required

Parent's Phone Number This field is required

Directions: Each rating should be considered in the context of what is appropriate for the age of your child. When completing this form, please think about your child's behaviors in the past 6 months.

Is this evaluation based on a time when the child… *

was on medication was not on medication not sure

Please choose one

Symptoms

0 = Never · 1 = Occasionally · 2 = Often · 3 = Very Often

1. Does not pay attention to details or makes careless mistakes with, for example, homework

0 Never 1 Occasionally 2 Often 3 Very Often

Please choose one

2. Has difficulty keeping attention to what needs to be done

0 Never 1 Occasionally 2 Often 3 Very Often

Please choose one

3. Does not seem to listen when spoken to directly

0 Never 1 Occasionally 2 Often 3 Very Often

Please choose one

4. Does not follow through when given directions and fails to finish activities (not due to refusal or failure to understand)

0 Never 1 Occasionally 2 Often 3 Very Often

Please choose one

5. Has difficulty organizing tasks and activities

0 Never 1 Occasionally 2 Often 3 Very Often

Please choose one

6. Avoids, dislikes, or does not want to start tasks that require ongoing mental effort

0 Never 1 Occasionally 2 Often 3 Very Often

Please choose one

7. Loses things necessary for tasks or activities (toys, assignments, pencils, or books)

0 Never 1 Occasionally 2 Often 3 Very Often

Please choose one

8. Is easily distracted by noises or other stimuli

0 Never 1 Occasionally 2 Often 3 Very Often

Please choose one

9. Is forgetful in daily activities

0 Never 1 Occasionally 2 Often 3 Very Often

Please choose one

10. Fidgets with hands or feet or squirms in seat

0 Never 1 Occasionally 2 Often 3 Very Often

Please choose one

11. Leaves seat when remaining seated is expected

0 Never 1 Occasionally 2 Often 3 Very Often

Please choose one

12. Runs about or climbs too much when remaining seated is expected

0 Never 1 Occasionally 2 Often 3 Very Often

Please choose one

13. Has difficulty playing or beginning quiet play activities

0 Never 1 Occasionally 2 Often 3 Very Often

Please choose one

14. Is “on the go” or often acts as if “driven by a motor”

0 Never 1 Occasionally 2 Often 3 Very Often

Please choose one

15. Talks too much

0 Never 1 Occasionally 2 Often 3 Very Often

Please choose one

16. Blurts out answers before questions have been completed

0 Never 1 Occasionally 2 Often 3 Very Often

Please choose one

17. Has difficulty waiting his or her turn

0 Never 1 Occasionally 2 Often 3 Very Often

Please choose one

18. Interrupts or intrudes in on others’ conversations and/or activities

0 Never 1 Occasionally 2 Often 3 Very Often

Please choose one

19. Argues with adults

0 Never 1 Occasionally 2 Often 3 Very Often

Please choose one

20. Loses temper

0 Never 1 Occasionally 2 Often 3 Very Often

Please choose one

21. Actively defies or refuses to go along with adults’ requests or rules

0 Never 1 Occasionally 2 Often 3 Very Often

Please choose one

22. Deliberately annoys people

0 Never 1 Occasionally 2 Often 3 Very Often

Please choose one

23. Blames others for his or her mistakes or misbehaviors

0 Never 1 Occasionally 2 Often 3 Very Often

Please choose one

24. Is touchy or easily annoyed by others

0 Never 1 Occasionally 2 Often 3 Very Often

Please choose one

25. Is angry or resentful

0 Never 1 Occasionally 2 Often 3 Very Often

Please choose one

26. Is spiteful and wants to get even

0 Never 1 Occasionally 2 Often 3 Very Often

Please choose one

27. Bullies, threatens, or intimidates others

0 Never 1 Occasionally 2 Often 3 Very Often

Please choose one

28. Starts physical fights

0 Never 1 Occasionally 2 Often 3 Very Often

Please choose one

29. Lies to get out of trouble or to avoid obligations (ie, “cons” others)

0 Never 1 Occasionally 2 Often 3 Very Often

Please choose one

30. Is truant from school (skips school) without permission

0 Never 1 Occasionally 2 Often 3 Very Often

Please choose one

31. Is physically cruel to people

0 Never 1 Occasionally 2 Often 3 Very Often

Please choose one

32. Has stolen things that have value

0 Never 1 Occasionally 2 Often 3 Very Often

Please choose one

33. Deliberately destroys others’ property

0 Never 1 Occasionally 2 Often 3 Very Often

Please choose one

34. Has used a weapon that can cause serious harm (bat, knife, brick, gun)

0 Never 1 Occasionally 2 Often 3 Very Often

Please choose one

35. Is physically cruel to animals

0 Never 1 Occasionally 2 Often 3 Very Often

Please choose one

36. Has deliberately set fires to cause damage

0 Never 1 Occasionally 2 Often 3 Very Often

Please choose one

37. Has broken into someone else’s home, business, or car

0 Never 1 Occasionally 2 Often 3 Very Often

Please choose one

38. Has stayed out at night without permission

0 Never 1 Occasionally 2 Often 3 Very Often

Please choose one

39. Has run away from home overnight

0 Never 1 Occasionally 2 Often 3 Very Often

Please choose one

40. Has forced someone into sexual activity

0 Never 1 Occasionally 2 Often 3 Very Often

Please choose one

41. Is fearful, anxious, or worried

0 Never 1 Occasionally 2 Often 3 Very Often

Please choose one

42. Is afraid to try new things for fear of making mistakes

0 Never 1 Occasionally 2 Often 3 Very Often

Please choose one

43. Feels worthless or inferior

0 Never 1 Occasionally 2 Often 3 Very Often

Please choose one

44. Blames self for problems, feels guilty

0 Never 1 Occasionally 2 Often 3 Very Often

Please choose one

45. Feels lonely, unwanted, or unloved; complains that “no one loves him or her”

0 Never 1 Occasionally 2 Often 3 Very Often

Please choose one

46. Is sad, unhappy, or depressed

0 Never 1 Occasionally 2 Often 3 Very Often

Please choose one

47. Is self-conscious or easily embarrassed

0 Never 1 Occasionally 2 Often 3 Very Often

Please choose one

Performance

1 = Excellent · 2 = Above Average · 3 = Average · 4 = Somewhat of a Problem · 5 = Problematic

48. Overall school performance

1 Excellent 2 Above Average 3 Average 4 Somewhat of a Problem 5 Problematic

Please choose one

49. Reading

1 Excellent 2 Above Average 3 Average 4 Somewhat of a Problem 5 Problematic

Please choose one

50. Writing

1 Excellent 2 Above Average 3 Average 4 Somewhat of a Problem 5 Problematic

Please choose one

51. Mathematics

1 Excellent 2 Above Average 3 Average 4 Somewhat of a Problem 5 Problematic

Please choose one

52. Relationship with parents

1 Excellent 2 Above Average 3 Average 4 Somewhat of a Problem 5 Problematic

Please choose one

53. Relationship with siblings

1 Excellent 2 Above Average 3 Average 4 Somewhat of a Problem 5 Problematic

Please choose one

54. Relationship with peers

1 Excellent 2 Above Average 3 Average 4 Somewhat of a Problem 5 Problematic

Please choose one

55. Participation in organized activities (eg, teams)

1 Excellent 2 Above Average 3 Average 4 Somewhat of a Problem 5 Problematic

Please choose one

Comments

Anything else you would like the provider to know (optional)

Prefer paper? Download the blank printable form

Copyright ©2002 American Academy of Pediatrics and National Initiative for Children’s Healthcare Quality. Adapted from the Vanderbilt Rating Scales developed by Mark L. Wolraich, MD. The information contained in this form should not be used as a substitute for the medical care and advice of your pediatrician.

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